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When I first began this blog late last year, I promised myself I wouldn’t talk about the fact that I have Addison’s Disease. I didn’t want it to outshadow other aspects of who I am and the validity of some content pieces I’ve written. The fact that I have Addison’s is something I’ve kept very private for the past couple of years. However, increasing interest in related topics (e.g. how to be active/athletic/live a balanced lifestyle while managing chronic illness) has come my way from friends and family members over the past few months, and I’ve found that sharing my own personal experiences, rather than hiding them, often gets people listening.

During late 2011 and early 2012, I experienced several fainting episodes, one of which landed me in the emergency room. Doctors–both those at my medical school, who witnessed the first two episodes, and those in the emergency room–automatically chalked it up to stress, fatigue, and the most common culprits for fainting in young women: postural orthostasis (low blood pressure), hypoglycemia, and/or some underlying psychiatric cause. I was basically told I was probably having a mild panic attack, and sent home. The third time it happened, I experienced the worst stomach ache of my life and began vomiting–something I hadn’t done in 15 or 16 years. That was the turning point–the point at which I realized that my low blood pressure wasn’t just low blood pressure. I had the standard battery of tests done (blood tests, an EKG, even an echocardiogram), which came back with the usual “abnormalities” for an endurance athlete: mildly elevated AST, low-ish blood sugar, very high HDL, very low heart rate, very low blood pressure, enlarged heart, etc. Nothing to be too concerned about. Again, I was sent home and told to force fluids, salts, and caffeine, if possible.

All the while, my general sense of wellness deteriorated rapidly from crummy to unmanageable. My occasionally-tired feeling suddenly became a very all-encompassing fatigue. I continued to push myself hard in running and cycling, but my workouts would only temporarily energize me and end up leaving me feeling totally beat a few hours down the line. As a medical student fresh off my didactic units in cardiovascular physiology, the endocrine system, and the gastrointestinal system, I was very wary of trying to diagnose myself–and to be quite honest, I myself was pretty convinced that whatever it was, was probably some nebulous, unnamed, “stress-induced syndrome” of sorts. I was, after all, going through the most stressful moments of my life coincidentally–for multiple reasons that don’t merit detail here.

Disenchanted with the western medical doctors I’d seen, I sought the help of a reputable naturopathic doctor and herbalist in Berkeley, California, where I was living at the time. To her credit, she nailed the diagnosis right on the head from the start–but I didn’t want to believe her. I knew what Addison’s Disease was; I had learned all about it in medical school and from my high school obsession with John F. Kennedy. But for some reason, despite my utmost faith in natural and alternative healing practices, I didn’t trust her diagnosis at the time.

It wasn’t until early 2013 that I was formally diagnosed by an M.D. in Boston: a well-known specialist in Addison’s Disease. Only then could I accept the diagnosis. Before I even felt disheartened about such a deterministic diagnosis, I felt remorse for my lack of acceptance of the naturopath’s wisdom. Being a huge proponent of the naturopathic route myself, I felt like an enormous hypocrite as well.

In time, I’ve learned how to manage my condition using both a blend of western and eastern medicines and philosophies. With trial and error, I’ve learned how to keep endurance sport part of my life. Most importantly, I’ve learned how to read the very subtle signs of my body, and respond to those signs with adequate rest and recovery.

Being athletic with Addison’s is something conventional doctors told me would not be possible. However, I have found a great wealth of knowledge and resources among holistic health practitioners, integrative nutritionists, yoga instructors, and others with Addison’s, all of which lend considerable credibility to the continuation of athletic endeavors.

Managing chronic illness is not always as simple as taking a pill every morning; it can become a lifelong investment in discovering what it means to practice self-care and to experience true wellness. My experiences in endurance sport have prepared me well for this “journey, not destination” mindset. And my continued exploration of whole plant-based nutrition, yoga, and spirituality has unearthed truths about healing and the mind-body connection that modern medicines fail to elucidate.

I’m thinking of writing a few posts on what it means to be an endurance athlete with a chronic illness, so stay tuned. Almost all of us have something we’re keeping an eye on on a daily basis, whether it’s biochemical, psychological, or “biopsychosocial” (that’s the new catch-phrase in neuroscience; or so I’m told). Hopefully I’ll be able to uncover some gems worth sharing.

In health,

Javej

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Disclaimer: the word “idiot” in the title of this post is by no means meant to be directed at readers; on the contrary, it’s my default way of being self-deprecating while writing these posts as if journaling to myself. Soon to come: “How to overcome unbridled self-deprecation as an endurance athlete.”

My last post, “I quit Facebook, canceled my subscription to Runner’s World, and erased my training log. Here’s why” received so much positive feedback and enthusiastic sharing of similar experiences from readers that I felt almost immediately inspired to expound upon my adventures in living the analog life–more specifically, how living relatively unencumbered by technology-driven distractions has improved my life as a recreational athlete (I could easily elaborate upon the benefits of this lifestyle in my personal and professional lives, but I’ll spare you the boredom and stick strictly to my badass, ninja, double-life which involves superhuman feats of strength, power, and will).

The theme of this blog post is centered around my newfound—and I use the word “newfound” cautiously—appreciation of how to move and train mindfully. The reality is that this skill is not so much newly found as rediscovered—something that has always been there, lurking just beneath the veneer of GPS watches and dubstep music turned to max volume. Each of us possesses a degree of wisdom within our musculoskeletal and neuromuscular systems that can be easily ignored, beaten into submission, or eclipsed by the sheen of a training plan. But what happens when we remove the agenda (mind) and just listen, feel, and experience (full inhabitation of body)?

This is risky, right? With structure comes progress (pretty much scientifically proven at this point) and accountability. Apply a specified, tried-and-true algorithm and, barring any rare medical complications, one can expect a certain outcome. I like this. I like science. I like applying evidence in order to forecast predictable outcomes.

Stripping myself of the comfort blankets that are my training journal, watch, and GPS was, quite frankly, terrifying for me. This was for several reasons, but among them: fear of boredom, fear of failure, lack of trust in myself to follow through, lack of trust in my body to progress, and attachment to the numbers/data game.

So I adopted something I could cling to: RPE. RPE, or “Rated Perceived Exertion” (a.k.a. “Borg scale”) refers to a numeric scale frequently used in exercise science research. The scale is completely subjective; in other words, it’s based entirely on an individual’s personal perception and concept of relativity. The idea is simple: on a scale of 6-20, how intense is your effort right now? (If 6-20 seems like an arbitrary range, rest assured it’s not–it’s based on heart-rate equivalents. It’s math.) For reference, 6 is lying on the couch, 11 is “light” activity, 15 is “heavy” activity, and 20 is “maximal exertion.” How the subject chooses to define “light” and “heavy” is up to him or her. Obviously one person’s light may be another person’s heavy depending on fitness, pain tolerance, and an incalculable number of other factors, but that’s beside the point. The point is to create a relative scale unique to each person, in order to gauge his or her psychological response to physical exertion in a given exercise session. Using RPE can be a useful tool for structuring a workout: intervals of alternating 12 and 15, or 17 effort uphill and 11 effort downhill, etc.—all while sidestepping the common pitfalls of using more traditional training tools (most notably, overtraining). RPE gives numerophiles such as myself something ordinal and organized, while also evading the possible dangers of too intense a focus on objective readouts (such as heart rate, speed, etc.).

Let me tell you something: RPE WORKS. It takes a little getting used to, but once you’re there, you’ve done it. You’ve figured out how to beat the system. But only if you play your cards right (in other words, no slacking!).

Here’s what using RPE requires: intense laser-focus on the present moment; constant and vigilant assessment of physical experience; unabashed honesty and ability to practice being objective with oneself; finely-tuned mind-body awareness; ability to interpret physiologic readouts; mental flexibility; and nuanced ability to ascertain when pushing limits is acceptable and beneficial.

Here’s what an RPE-driven workout looks like: start out at a warm-up pace, and once you get to that point where the engine feels good and revved, push a little more speed or power for a discrete period. Mind you, this is all based on feel. Don’t push it too hard or too fast right out of the gates; rather, wait until you’re well into glycogen utilization (or beta oxidation, whatever you’re going for) to push into higher gears. This will become apparent not when you feel like you “should” start to speed up but when your body starts to crave it. I usually hit a point where I am ready to push myself pretty hard (15-19 on the Borg/RPE scale), and then I go for it for as long as it feels doable, maybe plus 15-25% for good measure. I let myself recover for a little while, but not too long, before messing around with lactate threshold again. Then when my body starts to feel like it’s breaking down, like I’m losing my form, I’ll reel it in and call it a day.

This is what my RPE approach to training looks like, but this is by no means a one-size-fits-all approach. I really enjoy interval training and have found this to be a great way to fine-tune my ability to put forth honest efforts while also maintaining complete immersion in the present moment. My regimented, schedule-oriented, left-brain self is actually a fan. And my performance has improved dramatically since January by training this way, despite the fact that my workouts are shorter (at least I think they are…I’m not measuring time, so I honestly have no clue. Similarly, my “performance improvement” is entirely subjective…but I just feel much stronger, lighter on my feet, etc.).

Interestingly, training by RPE also opened up a wormhole into a world oft despised (or even discredited) by endurance athletes: weight training. Running and swimming by RPE has made me keenly aware of any and every weakness in my kinetic chain like never before. Suddenly I am flooded with the sensations of specific muscles contracting and relaxing during movement; this is an overwhelmingly cool sensation, and also a wake-up call: my pelvis wasn’t nearly as stable as I thought it was while running, and my glute medius was all but shot; my pectorals were taking up far too much slack during freestyle and I’d need to do some serious work on strengthening my lats; my core and lower back weren’t doing nearly as good a job as they could be. Weak glutes during a run are bad enough as is; but try experiencing them on a whole other level while experimenting with total mind-body immersion practices. It’s horrific. Each step is like nails on a chalkboard: a glaringly uncomfortable and disorienting nagging sensation that was on the verge of driving me to insanity. So I started hitting the weights again. And surprisingly, I haven’t hated it this time around. I think it might have something to do with being fully present and mindful while doing it.

Through all of this, there is one thing I haven’t left by the wayside, and that is this: music. While I do strive for completely distraction-less living some day, I had to start somewhere, and music has been a nice crutch throughout the transition. My feelings on music also straddle the divide: on the one hand, it can be terribly distracting, but on the other hand, the right song can really help endow me with the laser focus I’m looking for. I suppose it’s all a matter of knowing how and when to use music as a tool.

Perhaps that could be said for all of the training tools—watches, GPS devices, training logs, etc. Perhaps it’s all about knowing how and when to use them effectively, while tempering the desire to go off the deep end and become too encumbered with slaving away to them.

This, however, requires a certain degree of moderation and, as I’ve stated before, moderation has always eluded me and to this day, continues to do so.

I guess that just comes with the territory of being an endurance junkie.

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As much as I love running and cycling, the simple fact of the matter is that physics works against me in these endurance-oriented sports. At just over 5’10” (178 cm) and a buck fifty (68 kg), I’m more of a draft horse than a thoroughbred. According to science, the principles of basic physiology dictate that my body type is better suited to tennis than triathlon.

While watching the Sochi Winter Olympics over the past couple of weeks, I was surprised to find that many of the female athletes share in my relatively larger build–and in sports I wouldn’t expect. In many of the winter sports, height and weight are relevant factors–think about how dependent events like downhill skiing, bobsled, and luge are upon gravity and momentum–and so athletes’ proportions, along with their ages and representative countries, are flashed up on the screen next to their names.

Imagine my surprise to find that the women in luge and skeleton are all around my height and weight. Firstly, I had wrongly assumed that these sports would favor shorter athletes–something about soaring down an icy track, face-first, at 80+ mph on a tiny sled just intuitively seems more possible with a smaller build–but what do I know about skeleton anyway? Secondly…could skeleton and luge be any greater a departure from distance running?! I had quite a laugh at this realization. No wonder some of my long runs feel so awkward, I found myself thinking aloud–and since this weekend, I’ve found myriad excuses (“It’s the laws of physics!”) to justify my bumbling, eternal middle-of-the-pack status in the endurance world.

As an osteopath, my curiosity was piqued by the finding that athletes within certain disciplines have started to cluster around certain heights and weights. Certainly there are outliers, superhuman exceptions to the rule, but generally speaking it’s favorable to have long, gangly limbs (read: wingspan) in sports such as tennis and basketball, and also favorable to have a smaller, lighter frame for distance running (but thanks to Paula Radcliffe, who stands at a “towering” 5’8” [173 cm], marathoners clearly can be giants after all, right?). Much of this is elucidated in a fascinating foray into the overlap between genetics, innate talent, body structure, and environment: David Epstein’s book, The Sports Gene, which I highly recommend.

So what was the verdict? What does science say my body type is best suited for? Well, beach volleyball–with crew and tennis coming in close seconds. In winter sport, given that skeleton racer Noelle Pikus-Pace and alpine ski racer Lindsey Vonn are both exactly my size, I’ll gladly accept these daredevil events as my true Olympic calling.

Skiing, sledding, and beach volleyball all seem like an awesome time. But what’s my heart’s true calling? It’s still those darned running shoes. Awkward or bust!

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A couple of weeks ago I wrote a post titled, “Oops…I overtrained. Again.” This post, a brutally raw admission of my constant struggles to maintain a balanced, healthy training regimen, was not easy to write. I had a really great autumn season this year, training for nothing in particular but coming off a rest-filled summer with the gusto and enthusiasm of a newbie. But suddenly, like a ton of bricks, a deep fatigue set in around the end of December–a fatigue that was all-too-familiar, and surely indicative of my overdoing it, yet again. I was met with a pervasive, intuitive sense that if I didn’t take a rest week (or two), I’d crumble. I’d hit a physical limit.

It can be incredibly humbling to meet one’s own limitations, whether physical, psychological, or emotional. At the same time, it can be excruciatingly difficult to tease apart the subtle nuances through which psychology and emotion are intermixed with our physical capacity–especially in endurance sport. When was the last time you heard someone refer to an endurance event as [at least] “90% mental?” For me, it was only a few days ago. Anyone who’s run a marathon or done a long-course tri knows this as fact–and probably has this mantra engraved across his consciousness as gospel. And I tend to agree that the mind is the biggest player–for most of us mere mortals, at least.

But what about those times when the cold, hard boundary of our physical limitations is actually hit, head on? How do we know when to put our egos in our back pockets and keep soldiering on, and how do we know when it’s time to stop?

I have never had a problem motivating myself to keep going in a long race after “hitting the wall”–with enough pep talk, those last few miles, although painful, slowly begin to melt away. However, I have plenty of friends who hold DNFs to their names, and I expect my turn is coming soon. Most professional athletes also boast DNFs, but I think that’s a little bit of a different story given that many of them are attempting to defend titles and personal records; a DNF can be a good way to save face as a pro. That aside, I remain curious about age-group DNFers.

If I were a psychology grad student, I might make a dissertation out of interviewing DNFers to try to elucidate their thought processes when they decided to withdraw from a race. What physical limitations did they experience? How did they know when they’d reached the “point of no return”? Did the decision feel more voluntary, or more essential for survival?

I recently started watching a Discovery channel documentary series following a team of mountaineers up Everest. One of the crew members, an ultra-fit Danish triathlete with an incredibly endearing, humble personality, is attempting to summit without oxygen–the holy grail of Everest climbing–after three prior unsuccessful attempts. Despite a personal history of severe asthma, Mogens Jensen pushes on with vigor and a charmingly positive attitude. I imagine all audiences following this documentary cheering hard for this delightful Dane, who displays the classic “90% mental” attitude so characteristic of his endurance sport roots.

Unfortunately, Mogens decides–or is forced, rather–to turn back a mere 350 meters from the summit of Everest due to severe frostbite secondary to oxygen deprivation. Obviously this is a rather extreme example, but I wonder how Mogens came to the conclusion that it was time to turn around–especially after encountering numerous prior obstacles that would have sent anyone else scurrying back down the mountain face. How did he know he’d hit that “point of no return”? Plenty of mountaineers push on through frostbite; some make it, some don’t. But Mogens seemed to possess an uncanny ability to understand exactly when he could push on, and when he absolutely needed to stop. He was so close to clinching that dream–and after three prior attempts at that–but he knew that he had to relinquish it this fourth time.

Perhaps most indicative of this minor tragedy was the team guide’s response to Mogens’ defeat. Russell Brice, one of Everest’s most seasoned mountaineers and guides, notes that while he would have been extremely impressed by an asthmatic summiting Everest sans oxygen, he was considerably more impressed by Mogens’ very wise ability to sense exactly what he was dealing with.

This art is utterly beyond me, but I imagine with more experience I’ll have a better understanding of how to interpret the fine gradations of physical wellbeing. Until recently, there was little incentive to develop this talent; I’d always had fine success pushing through and finding comparable alternatives rather than stepping back. More recently, I’ve hit an obstacle that feels a little more concrete–a wall that won’t budge. For the first time in my life, I can’t simply charge through like a rhinoceros at full-speed: rather, I have to stop and turn around–or even better, find a creative way to circumnavigate the boulder blocking my path.

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I’m sure we’ve all heard this oft-referenced Einstein quote before: “The definition of insanity is doing the same thing over and over again and expecting different results.”

Well, the evidence is clear. I’m officially insane.

Einstein seems to have been right about everything (I’d like to point out that he was also a very strict vegetarian).

I encountered my first brushes with overtraining during my second year of medical school. A combination of intense, drawn-out, daily trail runs and mounting stresses from my life outside of the mountains ended up being a recipe for disaster. Hugely in denial, reluctant to give up the one thing I felt was serving me at the time (trail running), and being the know-it-all med student I was (smack in the middle of my endocrine unit, nonetheless), I did what any running addict would do: I just kept running.

They say hindsight is 20/20, and in retrospect, I recognize today just how stupid this was. I had all of the classic symptoms of what is referred to in the sports medicine literature as uncompensated overreaching-induced overtraining syndrome: debilitating lethargy, complete lack of motivation, mental fog, slowed heart rate, orthostatic hypotension (e.g. “seeing stars” every time I stood up), decreased appetite, and fitful, unsatisfying sleep. Basically, the concept here is that if an athlete does not compensate (a.k.a. “rest”) after overreaching (a.k.a. pushing hard for a couple of days or even a week), an almost inevitable outcome is insurmountable stress overload on the body: hormonal systems are suppressed, neurotransmitters shut down or dysregulated entirely, oxidative damage skyrockets, inflammation goes unchecked, and a deep, unshakable fatigue settles into the very bones of one’s body. It really kind of sucks.

The physician in me knows today—and even back then, knew—exactly how to remedy this. It was fairly clear that I was in the early stages of some sort of adrenal insufficiency, and perhaps even hypothyroidism, induced by overtraining, and the natural sequela would be Addisonian Crisis if I didn’t just stop, take the time to recover, nourish my body appropriately with rest, nutrition, and adaptogens, and re-hash my approach to running and training. Instead, I’d down a couple of cups of black coffee, take a pretty heavy-hitting dose of Siberan Eleuthero, and be jazzed up enough to convince myself I was fine.

I rarely felt bad during a run. But it was afterward that I’d feel like I’d been hit by a bus.

I employed stopgap therapies to try and fix the problem while still being able to run large volumes on a daily basis. I took supportive, adaptogenic herbs by the fistful. I set an early bedtime and tried to force myself to sleep for 9, 10, 11 hours a night. I took melatonin, licorice, ginseng, ashwagandha. I even stopped being vegan and started eating meat and eggs for a period of about four months. I only felt worse.

The answer was clear: I needed to rest. By six months into my stint with chronic overtraining, I had read nearly every medical journal publication out there on the subject. I was an expert. Every description pointed to exactly what I was experiencing. And the recommendations at the end of each publication were unequivocal: rest was the primary solution. In some cases only a few weeks of rest do the trick; in others, athletes toe the line between chronic burnout and wellness for years or even decades. Years? Decades?! Even the concept of weeks was unfathomable to my endorphins-hooked brain.

Rest was never an option for me. If I stopped being my endurance junkie self—admittedly, an enormous slice of my identity—then just who would I be?

I would be just another twenty-something girl. Just another medical student. Just another sister, daughter, friend, and girlfriend. While I appreciate these aspects of my identity enormously, I can’t help but admit that they feel frighteningly banal in comparison with my identity as an endurance sport lover.

So what did I ultimately end up doing? I continued to live in denial for another year or so, but during the spring of 2013 my behavior caught up with me. At the time, I was living in New York, but flew back to San Francisco to attend to some school-related things and visit my sister. I distinctly remember feeling so tired, so foggy, and so out of it while I was there. I could hardly motivate myself to get up from the chair I was sitting in. Climbing up a small hill in Bernal Heights Park—a hill that normally would seem like child’s play to me—I felt my heart thumping wildly in my chest and my blood pressure dropping precipitously. I felt so weak that I was sure I was going to pass out. While everyone else around me was enjoying the view and enjoying their lives, I was seeing stars and wishing I could crawl under the covers. That was the catalyst. When I flew back to Connecticut to spend a few days with my parents, I completely broke down, and resolved to give several weeks of rest a genuine try.

It was extraordinarily difficult at first, and I have to admit, it didn’t get much easier. As someone who has grown psychologically accustomed to being very physically active on a daily basis, putting the lid on training for a while was agonizing. I traded my long runs for long walks and long cuddle sessions on the couch with my dog. I dabbled in gentle and restorative yoga. I drank green juices and ate avocados by the bushel. All the while, I felt mentally restless. It was hard to see my running shoes stare up at me from the depths of my closet floor each morning. I had to put them in the basement.

I took some time to rest last summer, and got back into the swing of things last fall. Yet, like any endurance junkie, my tendency to overdo things—without realizing I’d overdone it until far, far after the fact—got the best of me. So here I am, in January, looking back at my insane training log from November and December and, from a logical perspective, not wondering in the least how I’ve managed to find myself in the same exact predicament.

Remember that definition of insanity? Yeah, that’s definitely me.

So what conclusions have I come to as a result of experiencing this? And what advice would I give?

Well, for one, overtraining is definitely a very real thing—and not something to be messed with. Secondly, I think it’s critical that anyone involved in very taxing and stressful endurance sports on a regular basis honestly assess his or her ability to cope with stress, period, at any point in life. At the time when I first began experiencing symptoms, I was puzzled as to why—I had, after all, had no problem recovering from similarly intense levels of activity in previous years. Why such a sudden and drastic shift? It is now clear to me that the non-physical stresses in my life at the time–the unending demands of medical school, the sadness of a failing long-term relationship, confusion and distrust of my own body through experiencing illness–were all taking an enormous amount out of me as it was. Add to that the stress of endurance exercise, which is well-documented to interfere with some of the body’s most vital functions, and overtraining becomes a distinctive possibility.

As I’ve opened up to friends and family about this rather humbling experience, I’ve been met time and time again with a very similar response: “Imagine how much better of a doctor this will make you!” Very true words, but they don’t console the fact that I can’t bust out 18-mile runs every day a la Dean Karnazes. Bummer.

Alas, I suppose I am only human after all. I guess I actually do have to take rest days.

The question, then, is this: what to do with all of the extra free time I’ll gain by having rest days?

Maybe go swimming?

Meh, once an addict, always an addict…

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Injury. It’s the endurance athlete’s worst nightmare. It’s an almost inevitable experience that comes with being a runner. Heck, my personal experiences with sports-related injuries have been so poignant as to drive me to center my career around identifying and treating them.

I currently run more based on how I feel than any set training plan; that said, most of my runs are over ten miles. Some weeks I run up to 60 miles, other weeks I might run 20. However, there was a distinct period of time, several years ago, when I noticed my body starting to break down if I went over 30-35 miles per week. Fearing injury and almost constantly plagued with some strange ache, pain, or tightness, I kept my mileage capped at less than 40 miles per week. Looking for a more sustainable way to continue running and also up my mileage, I started to tinker with my habits and daily practices to find a long-term plan to keep me running strong well into adulthood.

We are all an experiment of one, and here’s what I’ve cooked up in my laboratory so far when it comes to preventing running-related injury for myself. My disclaimer is that what works for me might not work for everyone. That said, I came to these methods after years and years of trial-and-error, and only after I’d mustered up the courage to break away from some of the classic dogma that has come to define running as a sport irrespective of science.

I hope these prove useful, and if anyone has any additional insights or experiences to offer, please post in the comments below!

Not my legs. But a girl can dream, no?

1. I stopped running every day. Prior to 2012, I let my ego get in the way and was intent on running every.single.day. I wanted to be a “streaker“–and I succeeded somewhat, running at least one mile every day for 1,812 consecutive days (or just shy of five straight years). I ran through many minor running injuries, employing band-aid and stopgap therapies to keep me on my feet. However, a traumatic knee injury brought that chapter of my life to an abrupt standstill, and through rest and periodization of training, I learned so much about how my body responds to and recovers from running. In fact, I not only healed well from my injury by significantly cutting back on my running, but I also got faster!

I can’t say that running less is what caused my improvement so much as an integration of all of the following practices listed below. Regardless, I really do think there’s something to taking at least one–but preferably two or three–days off between runs to allow the body time to repair all of the microdamage that occurs to bones, joints, and connective tissue during the run. Today, I run 2-3x per week, but I make those runs really count. I also never run if I don’t feel fully “healed” from my prior running session. I haven’t had an injury in the two years since I’ve implemented this practice.

2. I started pushing heavy resistance. Want to bulletproof your legs? Pedal backwards on the elliptical, at the highest resistance you can maintain for a minute at 150-180 rpm. Rest. Repeat.

I know “elliptical” is a dirty word among running purists, however for me, high resistance training on the elliptical and bike has been the cornerstone of keeping my legs super strong. Pushing heavy resistance here doesn’t mean classic weight training, although I know that targeted strength training can have huge benefits for injury-prone runners. Instead of doing endless squat and lunge variations, which I find cause flare-ups in my patellofemoral pain, I have found that pushing heavy resistance on low- or non-impact cardio equipment, such as bikes and ellipticals, has a significant impact on my ability to push power as well as withstand pavement pounding.

I think that high resistance and lower cadence, especially on the bike, is underrated. This method of training improves both strength and cardiovascular endurance as well as VO2max, and can be sustained for longer periods if done in an interval format. I have had to do some experimentation to find out which types of ellipticals work for me, since some position my feet awkwardly in the foot pedals and screw with my kneecap tracking. Generally speaking, though, the higher-end ellipticals (Precor, Cybex) that allow the user to alter incline and direction in addition to resistance really provide the most bang for your buck, as they allow you to truly tax every major and minor muscle group in the lower body, depending on angle and direction.

4. I rotate my running shoes. I rarely wear the same shoe two runs in a row. These days, I am running in everything from super minimalist (New Balance Minimus trail shoe, Vivobarefoot Breatho trail shoe) to super maximalist (Hoka One One Bondi B) to everything in between (Mizuno Wave Rider, Pearl iZumi EM Road H3, Brooks Pure Flow, Nike Free 5.0). As an osteopath and biomechanics nerd, I have come to understand that variety, and keeping the body constantly guessing, are key to injury prevention. I keep a wide variety of radically different shoes on heavy rotation, because each shoe causes a very subtle and slight change in my gait, foot strike, and stride, stressing different muscles and aspects of connective tissue. This is why, at least anecdotally, trail runners are far less likely to experience injury than road runners–they are constantly mixing up their terrain, and landing in novel ways depending on the surface presented to them. As for whether or not there is one optimal and pure foot strike for everyone, well, the jury’s still out on that one. But striving to land midfoot certainly can’t hurt.

5. I stopped stretching so much. Disclaimer: I am already incredibly flexible, and prone to hypermobility. In fact, it was my tendency to have hypermobile joints that caused me to injure my knee several years ago, when my kneecap became dislocated. Someone like me needs to work more on restoring stability and strength to the knees, ankles, and hip girdle rather than encouraging them to become even more lax through extreme yoga postures and stretching. If I feel specific tightness in a certain area, I hit the foam roller instead–that way I can target the muscle belly, rather than risk overstretching tendons, ligaments, joint capsules, etc.

6. I alkalized my diet. What does that even mean? Simply put, it means I have made fruits and vegetables comprise the vast majority of my diet. Because of the vitamins and minerals present in plant foods, along with the process by which they are digested, fruits and vegetables encourage the blood as well as body tissues to shift their pH from a more acidic to a more alkaline state. An alklaline state is a healing state; it is naturally anti-inflammatory, and encourages the healing of tissues as well as improved immune function. You can imagine what this means not only for injury recovery, but also for keeping injury at bay.

Alkalinizing foods include pretty much anything fruit and vegetable. On the flip side, acidifying foods include concentrated protein sources (especially animal products such as meat, eggs, and dairy; but also concentrated vegetarian proteins such as tofu, tempeh, seitan, etc.), some oils, some grains, refined flours, refined sugar, and certain fats. Most whole grains, nuts/seeds, legumes, and pulses are either neutral or very slightly acidic.

Highly acid-forming foods, especially animal protein, have such a profound effect on blood pH that eating even moderate amounts can encourage the body to leach calcium from bones, causing demineralization as calcium serves as a very potent buffer of the acidic conditions. Sounds like a recipe for a stress fracture to me.

So, long story short, I eat tons and tons of fruits and veggies. As much as I can. That’s not to say I don’t eat acid-promoting foods; as a whole foods vegan, grains, nuts, seeds, etc. are an important part of my diet. I just eat them in much smaller amounts.

7. I ignored the scale. Many runners tend to be a little too weight-obsessed, in my opinion. Obviously being somewhat on the lighter side is an advantage, but only up to a point. In my experience, I found that I was actually–and this may seem paradoxical–far more injury prone at a lower weight. Why? I’m not sure exactly, but more and more evidence is lending itself to the notion that nutritional status–especially among women–is a crucial component of the body’s ability to deal with stressful exercise, both on a hormonal level as well as a musculoskeletal level. I think that most of us have a “sweet spot” where are bodies are most nutritionally replete while also balancing athleticism and power. We may not look like Kara Goucher or Josh Cox at said sweet spot, but who gives? Running isn’t about how we look anyway–it’s about how we feel. Right? Who’s with me?

8. I stopped weight training. See #2 and #3. While I do still do some strength work, I have found that classical weight training aggravates my joints, especially in my lower body, a little too much to be worth it. I have found high intensity, high resistance cross-training to be more than sufficient in making my lower body strong and bulletproof.

9. I nipped niggles in the bud. Say wha? Okay, this term–“niggle”–is one I stole from Chrissie Wellington. She refers to little odd aches and pains, muscle tightness at an early stage, etc. as “niggles.” A niggle is that very subtle sensation of tightness in your IT band that occurs after a long run. It’s that slight cramp in your calf after a hill workout. Nipping it in the bud involves attacking it–not too aggressively, though–at first sign. My methods of choice involve foam rolling, Epsom salts baths, magnesium oil, Po Sum On (a Traditional Chinese Medicine remedy), and osteopathic manipulative medicine (if I can cajole one of my poor unsuspecting osteopath friends to fix me!).

10. I trashed the ibuprofen. It is only on extraordinarily rare occasions (read: once every two or three years) that I use any sort of NSAID, such as ibuprofen (Advil, Motrin) or naproxen (Aleve). If I do feel that a certain amount of inflammatory pain is hanging around a little too long–which, to be honest, these days is a rarity–I prefer to use herbal anti-inflammatories, such as Boswellia Serrata and Cat’s Claw (both of which are evidence-based for their ability to attenuate musculoskeletal inflammation). These herbal medications have a lighter, more subtle effect than traditional synthetic NSAID drugs, and also have a lower side effect profile. Why not just go for the ibuprofen, you ask? Well, mounting evidence suggests that turning inflammation completely off, as NSAID drugs do, may not be such a good thing, especially when it comes to healing. Rather, a healthy level of post-exercise inflammation is an important impetus for the regeneration and renewal of muscles, tendons, bones, and joints. In summary, a small amount of inflammation encourages the body to recruit healing cells, such as white blood cells, fibroblasts, and chondrocytes, to areas of microtrauma, such as ligaments and tendons. So instead of popping “vitamin I” so I can run the next day, I take a day–or three–off.

So there you have it–my personal prescription for running pain-free high mileage.
How do you keep your running sustainable?